Nokea
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
- A. Elevate the leg and apply a sandbag to the entrance site.
- B. Increase the flow rate of intravenous fluids.
- C. Assess the color and temperature of the left leg.
- D. Document the finding as the left pedal pulse of +1/4.
Correct Answer: C
Rationale: A weak pedal pulse after cardiac angiography may indicate compromised blood flow. Assessing the color and temperature of the leg helps determine if there is ischemia or other complications.
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During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond?
- A. Ask for a demonstration of these exercises
- B. Explain that coughing should be avoided
- C. Review the client’s previous surgical history
- D. Document the client's understanding of teaching
Correct Answer: A
Rationale: Asking for a demonstration ensures that the client understands the proper technique for coughing and deep breathing exercises.
Biochemical abnormalities in a chronic carrier of hepatitis B are:
- A. Raised AST
- B. Low serum albumin
- C. Raised gamma GT
- D. Raised transferrin
Correct Answer: A
Rationale: The correct answer is A because chronic hepatitis B carriers often have raised AST (aspartate aminotransferase) due to liver inflammation. The other options are less specific or not typically associated with chronic hepatitis B.
A child with rheumatic fever begins involuntary, purposeless movements of her limbs. What does the nurse recognize that this indicates?
- A. Seizure activity
- B. Hypoxia
- C. Sydenham’s chorea
- D. Decreasing level of consciousness
Correct Answer: C
Rationale: As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenham’s chorea, manifested by involuntary, purposeless movements of the limbs.
A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5 mm of erythema without induration. What is the best initial nursing action?
- A. Document negative results in the client's medical record
- B. Repeat the test immediately on the opposite forearm
- C. Notify the healthcare provider for further evaluation
- D. Schedule the worker for a chest X-ray
Correct Answer: A
Rationale: Erythema without induration is not considered a positive result. Documentation of negative findings is appropriate.
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
- A. Black ulcers and dependent rubor
- B. Irregular ulcer shapes and severe edema
- C. Absent pedal pulses and shiny skin
- D. Hairless lower extremities and cool feet
Correct Answer: B
Rationale: Venous ulcers are typically irregular in shape and associated with severe edema, while arterial ulcers are more likely to present with absent pulses and cool extremities.